The American healthcare system is a paradox of excess and deprivation. The United States spends more money on medical care than other nation: $2.5tn in 2009, over $8,000 per person.

Yet 46 million Americans – 15% of the population – don't have any health insurance. They are disproportionately the working poor, often employed by small firms that cannot afford to offer healthcare coverage (most Americans under age 65 get health insurance from their employers). Even many insured Americans lack adequate protection against the financial risks of illness. Medical care is consequently a leading cause of bankruptcy in the US.

The American medical care system can, at its best, offer insured patients excellent care. But too often the system is not at its best. Studies show that the quality of medical services in the US is uneven. About half the time American patients don't receive recommended care. International comparisons don't show any consistent quality advantage for American medical care. On a range of international health statistics – life expectancy, infant mortality, mortality amenable to medical care – the US does not compare favourably to other nations.

These problems are hardly new. During the past 60 years, a succession of presidents – Harry Truman, Richard Nixon, Jimmy Carter and Bill Clinton – has tried and failed to over overhaul the American medical care system.

Now it is Barack Obama's turn. The Obama administration is pushing Congress to enact health reform legislation this year. And against all odds, Obama may pull it off.

The administration's strategy of moving quickly on reform (to capitalise on Obama's popularity), negotiating agreements with healthcare industry group (such as the pharmaceutical industry) to neutralise opposition and deferring to Democratic party leadership in Congress on the legislative details has mostly worked.

Already, three of the five Congressional committees tasked with writing health reform bills have approved legislation that is in line with the Obama administration's priorities. The legislation would substantially expand health insurance coverage by broadening low-income persons' eligibility for government programmes, creating new insurance options – including a government health insurance plan – for other uninsured Americans, providing subsidies to help Americans with modest incomes afford health insurance and requiring employers to either provide insurance coverage to their workers or pay a tax to the government.

The goal of these reforms is not to create an entirely new healthcare system. Rather, is to build on existing institutions while stitching together a more robust safety net that will stop so many Americans from falling though the cracks.

This is not ideal reform. The programme would not take effect until 2013, a costly delay given that over 22,000 Americans die each year as a result of not having health insurance. Nor will the programme achieve universal coverage. Many US residents – an estimated 17 million in 2019, with unauthorised immigrants accounting for half that total – would remain uninsured even after the reforms were fully implemented. Moreover, proposed policies to stem the rising costs of medical care are generally weak.

There is little doubt, though, that the legislation now making its way through Congress would be a tremendous improvement over the status quo. Many Americans stand to gain greatly from the increased access to health insurance and medical care that these reforms promise. And the costs of inaction are high. Absent reform, as many as 66 million Americans, including growing numbers of middle-class families, could lack insurance a decade from now.

It is encouraging, then, to see the progress that Congress and the Obama administration have made this year. Never before has the Untied States come so close to passing comprehensive health reform.

Yet serious obstacles remain. In order for health reform to pass this year, three major issues must be resolved.

First, Congress must find a politically viable way to pay the $1tn price tag for expanding insurance coverage. Second, there will have to be compromise on the controversial issue of whether to create a new government insurance plan – a reform strongly favoured by liberal Democrats but opposed by conservatives – as an option for the uninsured. Finally, a conference committee will have to reconcile differing House and Senate bills in a way that satisfies competing factions within the Democratic party (while perhaps attracting a few moderate Republicans in the Senate who can provide conservative Democrats with political cover).

Settling these and other contentious issues will not be easy. But having come this far, Obama has a strong incentive to see health reform legislation through. While promising efforts to change the healthcare system have unravelled under previous administrations, that does not mean reform will fail this time.

Obama's election, after all, is a reminder that history is not always repeated. Sometimes it is made.